As shown in Figure 1, our search retrieved 3080 citations during the initial detection by the search strategy. After screening titles and abstracts, 671 reports were included for full further text screening. Sixty-seven RCTs were eligible for meta-analysis ultimately.
These 67 RCTs[6–8, 16–79] were comprised of 3293 patients in the combination treatment group and 3301 patients in the control group. The mean age of included patients ranged from 42.2 to 71.5 years, and the sample size ranged from 40 to 300 patients. All RCTs were conducted among Chinese populations in China. Patients in the combination treatment group received Danhong injection 10-40 ml once or twice daily (Table 1).
Table 1
Baseline characteristics of included randomized controlled trials
Author (year)
|
Phase of disease
|
Sample size,
EG/CG
|
Mean age (year)
|
Interventions
|
Dosages of
Danhong Injection
|
Course
|
Outcomes
|
EG
|
CG
|
EG
|
CG
|
Cao 2020
|
Acute phase
|
49/49
|
63.11
|
62.47
|
rt-PA, DHI
|
rt-PA
|
Once daily, 20ml
|
14d
|
(1) (12) (14)
|
Cheng 2019
|
NR
|
20/20
|
58.40
|
56.10
|
Edaravone, DHI
|
Edaravone
|
Once daily, 30ml
|
14d
|
(14)
|
Zhang 2019
|
NR
|
55/55
|
53.80
|
53.20
|
Clopidogrel, DHI
|
Clopidogrel
|
Once daily, 30mg
|
28d
|
(14)
|
Deng 2019
|
NR
|
50/50
|
63.77
|
63.28
|
Edaravone, DHI
|
Edaravone
|
Once or twice daily, 20-40ml
|
14d
|
(1)
|
Li 2017
|
Acute phase
|
40/40
|
66.50
|
66.50
|
Edaravone, DHI
|
Edaravone
|
Once daily, 30ml
|
14d
|
(1) (4) (14)
|
Li 2017
|
Acute phase
|
30/30
|
61.48
|
62.03
|
Ozagrel Sodium, DHI
|
Ozagrel Sodium
|
Once daily, 40ml
|
14d
|
(1) (8) (9) (10) (11)
|
Wang 2016
|
Acute phase
|
35/37
|
NR
|
NR
|
Aspirin, DHI
|
Aspirin
|
Once daily, 40ml
|
14d
|
(3) (14)
|
Zhang 2015
|
Acute phase
|
50/50
|
58.60
|
60.30
|
Vinpocetine, DHI
|
Vinpocetine
|
Once daily, 30ml
|
14d
|
(1)
|
Yin 2014
|
Acute phase
|
60/60
|
52.80
|
53.10
|
Hyperbaric Oxygen, DHI
|
Hyperbaric Oxygen
|
Twice daily, 20ml
|
56d
|
(1)
|
Shen 2012
|
Acute phase
|
36/36
|
NR
|
NR
|
Edaravone, DHI
|
Edaravone
|
Once daily, 30ml
|
14d
|
(1) (4) (14)
|
Zhuang 2020
|
NR
|
56/56
|
61.11
|
61.15
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(1) (14)
|
Liu 2018
|
NR
|
83/83
|
NR
|
NR
|
Edaravone, DHI
|
Edaravone
|
Once daily, 20-40ml
|
14d
|
(1) (14)
|
Shi 2018
|
Acute phase
|
40/40
|
64.00
|
65.00
|
Alprostadil, DHI
|
Alprostadil
|
Once daily, 40ml
|
14d
|
(1) (4)
|
Yang 2018
|
Acute phase
|
47/47
|
NR
|
NR
|
Edaravone, DHI
|
Edaravone
|
Once daily, 40ml
|
14d
|
(1) (3) (8) (9)
|
Ma 2017
|
NR
|
40/42
|
60.01
|
65.26
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1) (2) (13)
|
Liu 2010
|
Acute phase
|
44/43
|
63.70
|
64.40
|
Fasudil Hydrochloride, DHI
|
Fasudil Hydrochloride
|
Once daily, 30ml
|
14d
|
(4) (14)
|
Chen 2017
|
NR
|
32/32
|
53.12
|
52.93
|
CT, DHI
|
CT
|
Once daily, 30ml
|
7d
|
(8)
|
Zhang 2018
|
Acute phase
|
54/54
|
61.80
|
60.20
|
Alprostadil, DHI
|
Alprostadil
|
Once daily, 30ml
|
14d
|
(1) (14)
|
Zhang 2017
|
Acute phase
|
45/45
|
68.90
|
69.30
|
Edaravone, DHI
|
Edaravone
|
Twice daily, 20ml
|
14d
|
(14)
|
Pen 2017
|
NR
|
39/39
|
NR
|
NR
|
Atorvastatin Calcium, DHI
|
Atorvastatin Calcium
|
Once daily, 10ml
|
14d
|
(5)
|
Fan 2018
|
Acute phase
|
35/35
|
49.32
|
50.45
|
CT, DHI
|
CT
|
Once daily, 40ml
|
14d
|
(1) (4)
|
Li 2017
|
Acute phase
|
48/48
|
55.76
|
56.37
|
Clopidogrel, DHI
|
Clopidogrel
|
Once daily, 30ml
|
14d
|
(1) (4) (14)
|
Jiang 2020
|
Acute phase
|
60/60
|
60.47
|
59.82
|
rt-PA, Sodium Heparin, DHI
|
rt-PA, Sodium Heparin
|
Once daily, 20ml
|
14d
|
(1) (5) (14)
|
Liu 2019
|
Acute phase
|
56/56
|
56.91
|
55.73
|
Edaravone, DHI
|
Edaravone
|
Once daily, 20mg
|
14d
|
(2) (3) (6) (7)
|
Liu 2017
|
NR
|
30/30
|
60.24
|
58.49
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(13)
|
Ge 2018
|
NR
|
37/37
|
62.13
|
61.52
|
Atorvastatin Calcium, DHI
|
Atorvastatin Calcium
|
Once daily, 20ml
|
14d
|
(1) (14)
|
Yun 2017
|
Acute phase
|
31/31
|
69.50
|
68.20
|
Aspirin, DHI
|
Aspirin
|
Once daily, 30ml
|
14d
|
(7)
|
Liu 2019
|
Acute phase
|
33/32
|
41.84
|
42.53
|
Butylphthalide soft capsules, DHI
|
Butylphthalide soft capsules
|
Once daily, 40ml
|
14d
|
(1)
|
Dai 2018
|
Acute phase
|
47/47
|
56.42
|
56.43
|
Aspirin,Nimodipine, DHI
|
Aspirin,Nimodipine
|
Twice daily, 40ml
|
15d
|
(1) (4) (8) (9)
|
Yang 2018
|
Acute phase
|
39/39
|
64.08
|
63.22
|
Atorvastatin Calcium, DHI
|
Atorvastatin Calcium
|
Once daily, 20ml
|
14d
|
(1) (3)
|
Li 2015
|
Acute phase
|
105/105
|
71.30
|
71.60
|
Edaravone, DHI
|
Edaravone
|
Once daily, 30ml
|
14d
|
(1) (8) (9)
|
Li 2020
|
Acute phase
|
52/52
|
68.34
|
68.58
|
3-n-butylphthalide, DHI
|
3-n-butylphthalide
|
Once daily, 30ml
|
14d
|
(1) (7)
|
Liu 2017
|
Acute phase
|
54/55
|
56.83
|
56.94
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1)
|
Luo 2018
|
Acute phase
|
56/56
|
65.40
|
65.10
|
CT, DHI
|
CT
|
Twice daily, 30ml
|
28d
|
(2) (14)
|
Kang 2020
|
Acute phase
|
65/60
|
55.42
|
54.95
|
Tirofiban Hydrochloride, Clopidogrel, Aspirin, DHI
|
Tirofiban Hydrochloride, Clopidogrel, Aspirin
|
Once daily, 20ml
|
14d
|
(1) (4) (14)
|
Yang 2018
|
Acute phase
|
58/58
|
57.86
|
57.09
|
Clopidogrel, DHI
|
Clopidogrel
|
Once daily, 30ml
|
14d
|
(1) (14)
|
Liu 2020
|
Acute phase
|
71/71
|
63.24
|
61.97
|
Edaravone, DHI
|
Edaravone
|
Once daily, 20ml
|
14d
|
(1) (3) (7)
|
Wang 2016
|
Acute phase
|
56/56
|
NR
|
NR
|
CT, DHI
|
CT
|
Once daily, 450mg
|
168d
|
(1)
|
Yuan 2019
|
Acute phase
|
38/38
|
65.50
|
65.39
|
Edaravone, DHI
|
Edaravone
|
Once daily, 40ml
|
14d
|
(1) (2) (3) (12)
|
Su 2012
|
Acute phase
|
38/37
|
61.58
|
63.01
|
CT, DHI
|
CT
|
Once daily, 40ml
|
14d
|
(8) (9) (11) (14)
|
Luo 2012
|
Acute phase
|
90/90
|
NR
|
NR
|
Ozagrel Sodium, DHI
|
Ozagrel Sodium
|
Once daily, 40ml
|
14d
|
(1)
|
Zou 2013
|
Acute phase
|
40/40
|
58.70
|
57.90
|
Vinpocetine, DHI
|
Vinpocetine
|
Once daily, 30ml
|
14d
|
(1)
|
Liang 2014
|
Acute phase
|
45/45
|
53.50
|
52.60
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(4)
|
Ma 2015
|
Acute phase
|
45/45
|
65.37
|
65.64
|
CT, DHI
|
CT
|
Once daily, 20ml
|
28d
|
(2) (3)
|
Fan 2015
|
NR
|
45/45
|
62.30
|
61.50
|
CT, DHI
|
CT
|
Once daily, 20ml
|
28d
|
(8) (9) (10) (11)
|
Zeng 2016
|
Acute phase
|
55/55
|
63.00
|
63.30
|
Edaravone, DHI
|
Edaravone
|
Once daily, 20ml
|
15d
|
(3)
|
Feng 2016
|
Acute phase
|
20/20
|
59.82
|
60.50
|
rt-PA, DHI
|
rt-PA
|
Once daily, 20ml
|
14d
|
(3) (13)
|
Ou 2017
|
Acute phase
|
60/60
|
58.10
|
57.20
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1) (4) (12)
|
Wu 2016
|
Acute phase
|
49/49
|
67.40
|
68.10
|
Alprostadil, Edaravone,
Aspirin, DHI
|
Alprostadil, Edaravone,
Aspirin
|
Once daily, 40ml
|
14d
|
(1) (3) (12) (14)
|
Chen 2017
|
Acute phase
|
40/40
|
67.34
|
66.46
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(2) (14)
|
Qiu 2017
|
Acute phase
|
58/58
|
70.69
|
69.88
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(1) (4) (8) (9)
|
Liu 2017
|
Acute phase
|
48/48
|
52.33
|
52.05
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1)
|
Wei 2017
|
Acute phase
|
47/47
|
62.60
|
60.73
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1) (14)
|
Jing 2020
|
Acute phase
|
44/44
|
62.70
|
63.20
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1) (3) (6) (7)
|
Li 2018
|
Acute phase
|
50/50
|
51.90
|
52.30
|
Atorvastatin Calcium, DHI
|
Atorvastatin Calcium
|
Once daily, 20ml
|
14d
|
(14)
|
Jin 2019
|
Acute phase
|
50/50
|
52.00
|
54.00
|
rt-PA, DHI
|
rt-PA
|
Once daily, 20ml
|
14d
|
(1)
|
Chai 2019
|
Acute phase
|
42/42
|
64.08
|
63.17
|
Ozagrel Sodium, Aspirin, DHI
|
Ozagrel Sodium, Aspirin
|
Once daily, 40ml
|
14d
|
(1) (4)
|
Chen 2019
|
Acute phase
|
74/74
|
54.69
|
52.61
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1)
|
Li 2019
|
Acute phase
|
42/42
|
63.49
|
63.58
|
Urinary Kallidinogenase, DHI
|
Urinary Kallidinogenase
|
Once daily, 20ml
|
14d
|
(1) (14)
|
Zhu 2020
|
Acute phase
|
30/30
|
56.34
|
57.62
|
CT, DHI
|
CT
|
Once daily, 20ml
|
14d
|
(1) (3)
|
Cao 2019
|
Acute phase
|
150/150
|
59.70
|
59.00
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(13) (14)
|
Song 2014
|
Acute phase
|
65/65
|
65.23
|
65.89
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(1) (3) (8) (9) (11) (13) (14)
|
Lv 2018
|
Acute phase
|
40/40
|
63.01
|
62.34
|
rt-PA
|
rt-PA
|
Once daily, 20ml
|
14d
|
(3) (14)
|
Huo 2020
|
Acute phase
|
45/45
|
NR
|
NR
|
Deproteinised Calf Blood Injection, DHI
|
Deproteinised Calf Blood Injection
|
Once daily, 30mg
|
14d
|
(1)
|
Cao 2016
|
Acute phase
|
34/33
|
54.50
|
58.90
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(1) (14)
|
Ren 2011
|
Acute phase
|
34/34
|
62.20
|
63.10
|
CT, DHI
|
CT
|
Once daily, 40ml
|
14d
|
(1)
|
Xue 2010
|
NR
|
37/49
|
65.70
|
67.50
|
CT, DHI
|
CT
|
Once daily, 30ml
|
14d
|
(5) (8) (10) (11) (14)
|
CG= control group; EG=experiment group (Danhong Injection group); NR=not reported; CT=conventional treatment. |
Outcomes: (1)=NIHSS, (2)=Fugl-Meyer Assessment, (3)=Barthel index, (4)=ADL, (5)=IMT, (6)=cerebral blood flow, (7)=average cerebral blood flow rate, (8)=total cholesterol, (9)=triglycerides, (10)=HDL, (11)=LDL, (12)=Hcy, (13)=D-dimer, (14)=ADRs. |
All RCTs reported methods of random sequences generation. None of the trials mentioned allocation concealment. Only three trials [31, 39, 52] (4%) blinded patients and caregivers. No trials mentioned loss to follow-up. No details were identified in the domains of other bias (Supplementary table 1).
Treatment effects
In total, 45 RCTs[8, 16, 19–21, 23–30, 33, 36–38, 40, 42–46, 48–51, 53, 54, 60, 61, 63–66, 68–72, 74, 76–78] involving 4565 patients reported NIHSS score. For Danhong injection combined with western medicine group, the NIHSS score significantly changed -10.50 (95% CI: -11.50~-9.51), and the control group changed -6.22 (95% CI: -7.05~-5.39). Meta-analysis showed that Dahong injection combined with western medicine had a better effect in improving neurological impairment than western medicine alone (NIHSS score MD -4.21, 95% CI -4.96~-3.46)(Figure 2).
Six RCTs[6, 30, 47, 51, 56, 62] involving 552 patients showed that Danhong injection combined with western medicine could significantly improve the Fugl-Meyer Assessment than western medicine alone (MD 14.28, 95% CI 9.47~19.09) (Figure 3). Compared with western medicine alone, Danhong injection plus western medicine suggested a significant improvement on Barthel index (14 trials with 1270 patients; MD 8.71, 95% CI 3.68~13.74) and ADL score (12 trials with 1114 patients; MD 14.48, 95% CI 9.04~19.92) (Figure S1 and S2 in appendix 3).
Meta-analysis showed that compared with western medicine alone, combination therapy of Danhong injection and western medicine could significantly lower the IMT (3 trials with 284 patients; MD -0.23 mm, 95% CI -0.26~-0.20), increase the cerebral blood flow (2 trials with 200 patients; MD 1.16 mL/s, 95% CI 0.64~1.68) and average cerebral blood flow rate (5 trials with 508 patients; MD 3.05 cm/s, 95% CI 1.61~4.50) (Figures S3-S5 in appendix 3).
The combination therapy of Danhong injection and western medicine could significantly lower total cholesterol (10 trials with 1019 patients; MD -1.14 mmol/L, 95% CI -1.57~-0.72) (Figure 4), triglycerides (8 trials with 869 patients; MD -1.00 mmol/L, 95% CI -1.69~-0.31) and LDL (5 trials with 441 patients; MD -0.91mmol/L, 95% CI -1.33~-0.49), and increase the level of HDL (3 trials with 236 patients; MD 0.31mmol/L, 95% CI 0.22~0.40) (Figures S6-S8 in appendix 3).
Four RCTs[16, 51, 60, 61] with a total of 392 individuals reported the data of serum Hcy level. The results revealed a significant lowering effect on Hcy in the Danhong injection combination therapy ( MD -3.54 µmol/L, 95% CI -4.38~-2.07) (Figure 5).
Meta-analysis of five trials with a total of 612 patients showed no statistically significant difference in D-dimer (MD -0.12mg/L, 95% CI -0.61~0.37, P=0.64) between treatment groups (Figure S9 in appendix 3).
Subgroup Analysis
Subgroup analysis by mean age showed differential effects in average cerebral blood flow rate (<60 years old: MD 0.74 cm/s, 95% CI 0.29~1.19; ≥60 years old: MD 4.09 cm/s, 95% CI 2.02~6.16; interaction P=0.002). The analysis by length of treatment showed differential effects in ADL (≤2 weeks: MD 15.08, 95% CI 9.11~21.05; >2 weeks: MD 8.18, 95% CI 6.21~10.15; interaction P=0.03). Subgroup analysis by type of baseline western medicines showed differential effects (conventional therapy: MD -3.79, 95% CI -4.83~-2.76; intravenous thrombolysis: MD -2.19, 95% CI -3.52~-0.86; anti-platelet aggregation: MD -3.79, 95% CI -5.06~-2.51; dilation of blood vessels: MD -4.23, 95% CI -5.85~-2.62; statins: MD -2.87, 95% CI -4.07~-1.67; neuroprotective agents : MD -5.88, 95% CI -8.90~-2.87; other therapies : MD -10.20, 95% CI -12.54~-7.86; interaction P<0.00001).
As for Fugl-Meyer Assessment, Barthel index, total cholesterol, triglycerides, LDL, Hcy and D-dimer, subgroup analyses by length of treatment, mean age of patients, and types of baseline western medicine treatment showed no statistically differential effects.
Safety
Of the 67 included trials, 16 studies [20, 22, 25–27, 31, 33, 34, 37, 40, 49, 62, 65, 67, 71, 75] reported at least one case of ADRs, 12 studies [16–18, 38, 47, 48, 52, 61, 73, 74, 77, 79] reported no ADRs/ADEs during the study, and 39 RCTs did not mention the information of ADRs/ADEs.
The main ADRs occurred during the trials were gastrointestinal reactions(4.48% vs 4.76% in Danhong injection plus western medicine and western medicine alone group, respectively, P=0.76), dizzy (3.69% vs 2.74% in each group, P=0.61) and skin rash (8.53% vs 7.31% in each group, P=0.56). ADRs occurred during the trials in either group were shown in Supplementary table 2.
Assessment of Publication Bias
The funnel plots for NIHSS, Barthel index and ADL were near asymmetric, and no important publication bias was detected by Egger’s tests (Egger’s test P=0.055, P=0.342 and P=0.998, respectively). Egger’s test of total cholesterol suggested potential publication bias (Egger’s test P=0.019). The sensitivity analysis by the trim-and-fill method showed that the results was robust despite the potential bias (trim-and-fill method adjusted MD -1.14 mmol/L, 95% CI -1.57~-0.72) (Figure S10-11 in appendix 3).